The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

CPT Notes

Prolonged services

Critical Care and Prolonged Care Codes Address Intensity of Family Physician Services from the American College of Osteopathic Family Physicians

From: http:

Prolonged services involve direct face-to-face contact between the physician and the patient that is beyond the usual service in either the inpatient or outpatient setting. The codes should be used to report the total duration of face-to-face time on a given date, even if the time spent by the physician on that date is not continuous. 

Subject Name: Prolonged Evaluation and Management Services and Standby Services

Subject Number: PHYS-031

Description:
Prolonged services involve direct face-to-face contact between the physician and the patient that is beyond the usual service in either the inpatient or outpatient setting. The codes should be used to report the total duration of face-to-face time on a given date, even if the time spent by the physician on that date is not continuous.

Procedure Codes CPT or HCPCS:

99354	Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (List separately in addition to code for service of other outpatient Evaluation and management Service)
99355	each additional 30 minutes (List separately in addition to code for prolonged physician services)
99356	Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour (List separately inaddition to code for inpatient Evaluation and management Service)
99357	each additional 30 minutes (List separately in addition to code for prolonged physician services)
99358	Prolonged evaluation and management service before and/or after direct (face to face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (List separately in addition to code(s) for other physician service(s) and/or inpatient or outpatient Evaluation and Management service)
99359	each additional 30 minutes hour (List separately in addition to code for prolonged physician service)
99360	Physician standby service, requiring prolonged physician attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)

Indications and Limitations of Coverage:

1. Prolonged codes can be billed only if the total duration of all physician direct face to face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician provided (typical time plus 30 minutes). If the total duration of direct face to face time does not equal or exceed the threshold time for the level of evaluation and management service the physician provided, the physician may not bill for prolonged services.
1. In the case of prolonged services, time spent by office staff with the patient, or time the patient remains unaccompanied in the office, cannot be billed.
2. In the case of prolonged hospital services, time spent waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities, cannot be billed as prolonged services.

 

 
 
 
 
 

2. Prolonged services without face-to-face service (codes 99358-99359) are not covered by Medicare. These services are included in the payment for direct face-to-face services provided by the physician.
3. Physician standby services (code 99360) are not covered by Medicare. Standby services are considered a service to the hospital and cannot be billed to the beneficiary. This is a Part A benefit.
4. Threshold times for codes 99354 and 99355. When the total direct face-to-face time equals or exceeds the threshold time for 99354, but is less than the threshold time for 99355, the physician should bill the visit and code 99354.

 

 
 
 
 
 

When the total direct face-to-face time equals or exceeds the threshold time for 99355 by no more than 29 minutes, the physician should bill the visit code 99354 and one unit of 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration. Refer to Appendix B to determine if the prolonged service codes 99354 and/or 99355 can be billed with the office/outpatient visit and consultation codes.

5. Threshold times for codes 99356 and 99357. When the total direct face-to-face time equals or exceeds the threshold time for code 99356, but is less than the threshold time for code 99357, the physician should bill the visit and code 99356.

 

 
 
 
 
 

When the total direct face-to-face time equals or exceeds the threshold time for code 99356 by no more than 29 minutes, the physician bills the visit code 99356 and one unit of code 99357. One additional unit of code 99357 is billed for each additional increment of 30 minutes extended duration. Refer to Appendix C to determine if the prolonged service codes 99356 and/or 99357 can be billed with the office/outpatient visit and consultation codes.

6. Documentation in the patient’s progress notes must support billing for prolonged services. Documentation does not need to be submitted with the claim but must be available upon request. The patient’s Medical record must document the duration and content of the E&M code billed and that the physician have personally furnished at least 30 minutes of direct service after the typical time of the evaluation and management service had been exceeded by at least 30 minutes.

Coding Guidelines:

1. List the appropriate prolonged care CPT code(s) with the appropriate companion E&M service provided; refer to appendix A.
2. Calculate the appropriate time involved and report according to information in Appendix B or C.
1. 99355 must be billed with 99354. 99357 must be billed with 99356.
2. For codes 99354 and 99356, only one unit of service per day is allowed
3. Additional time is reported with codes 99355 or 99357, with the units of service that reflects the total time.

 

 
 
 
 
 

Appendix A- Appropriate Companion Codes

Prolonged Code(s)	E&M Codes
99354 (office or outpatient)	99201-99205
99355 (office or outpatient)	99212-99215
	99241-99245
	99341-99345*
	99347-99350*
Prolonged Code(s)	E&M Codes
99356 (Inpatient)	99221-99223
99357(Inpatient	99231-99233
	99251-99255
	99261-99263
	99301-99303
	99311-99313

Appendix B-Threshold times for codes 99354 and 99355

Code	Typical Time  for code	Threshold time to bill code 99354	Threshold time to bill codes 99354 & 99355
99201 99202 99203 99204 99205 99212 99213 99214 99215 99241 99242 99243 99244 99245 99341* 99342* 99343* 99344* 99345* 99347* 99348* 99349* 99350*	10 20 30 45 60 10 15 25 40 15 30 40 60 80 20* 30* 45* 60* 75* 15* 25* 40* 60*	40 50 60 75 90 40 45 55 70 45 60 70 90 110 50* 60* 75* 90* 105* 45* 55* 70* 90*	85* 95* 105* 120* 135* 85* 90* 100* 115* 90* 105* 115* 135* 155* 95* 105* 120* 135* 150* 90* 100* 115* 135*

Add 30 minutes to the threshold time for billing codes 99354 and 99355 to get the threshold time for billing code 99354 and 2 units of code 99355.

Appendix C-Threshold times for codes 99356 and 99357

Code	Threshold time for code	Threshold time to bill code 99356	Threshold time to bill codes 99356 & 99357
99221 99222 99223 99231 99232 99233 99251 99252 99253 99254 99255 99261 99262 99263 99301 99302 99303 99311 99312 99313	30 50 70 15 25 35 20 40 55 80 110 10 20 30 30 40 50 15 25 35	60 80 100 45 55 65 50 70 85 110 140 40 50 60 60 70 80 45 55 65	105 125 145 90 100 110 95 115 130 155 185 85 95 105 105 115 125 90 100 110

Add 30 minutes to the threshold time for billing codes 99356 and 99357 to get the threshold time for billing code 99356 and 2 units of 99357.